Article November 2013, Vol. 5, No. 2 AJHPE 63 Background. A need for professional development in the training of registrars was identified by the School of Medicine, University of the Free State (UFS), Bloemfontein, South Africa, in 2007. Objective. To develop the module on Health Care Practice (HCP) (GPV703) to address these shortcomings. Methods. A quantitative study, enhanced by qualitative data, was conducted. A self-administered questionnaire that included a rating scale and open-ended questions was used. The quantitative responses were analysed using Microsoft Excel, and the qualitative data were edited, categorised and summarised. Results. The questionnaire was completed by 95% (n=38/40) of registrars. The quantitative questions, regarding the orientation session, content and applicability of the content of the module, showed satisfactory to very good responses. Of the 40 surveys collected from registrars, 77.5% (n=31/40) were completed by heads of department (HODs). The surveys showed a significant improvement in registrar competence: 17 were given an above- average rating and 14 an average rating; there were no below-average ratings. Discussion. The module on HCP, which is part of the MMed programme, addressed aspects required by registrars to develop and/or enhance their skills, knowledge and professional behaviour with regard to ethics, practice management and patient communication. Registrars were generally satisfied with the content and presentation of the module. The open-ended questions raised concerns about aspects of patient communication and electronic learning. These need to be addressed to improve the quality of the module. Conclusion. The module on HCP (GPV703), as implemented by the UFS, is successful in addressing key aspects often neglected because of the strong clinical focus of a medical programme. AJHPE 2013;5(2):63-67.DOI:10.7196/AJHPE.195 A reflection on professional development of registrars completing a module in Health Care Practice J Bezuidenhout,1 PhD; M M Nel,1 PhD; G J van Zyl,2 PhD 1 Division of Health Sciences Education, Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa 2 Office of the Dean, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Corresponding author: J Bezuidenhout (bezuidj@vfs.ac.za) In South Africa, the programme for the training of medical specialists (registrars) in a particular discipline leads to the postgraduate Master in Medicine (MMed) and/or the Colleges of Medicine qualification. The programme creates opportunities for postgraduate education and training in specific specialist disciplines ranging over a 4- or 5-year period. Registrars are appointed in specific departmental posts in the various specialties at the University of the Free State (UFS) in Bloemfontein, South Africa, by the Department of Health. Registrars completed their undergraduate training at one of the 8 South African medical schools or elsewhere, obtaining the qualification Medicinae Baccalareus, Chirurgiae Baccalareus (MB ChB).[1,2] The need to train registrars in aspects related to ethics, practice management and patient communication was identified by various reports from the Health Professions Council of South Africa (HPCSA) (unethical practice and misconduct)[3] and in meetings with various schools of medicine and deans.[4] The module evaluates registrars with regard to the latest international tends in ethics, HPCSA requirements for the management of a practice, and proper conduct related to communication when dealing with patients. Since 2008, registrars at UFS are required to complete the Health Care Practice (HCP) module as part of the MMed programme. It is offered during the first 24 months of registrar training and is a compulsory, attendance-based module in each of the disciplines. An orientation session is offered in addition to sessions on ethics, practice management and patient communication. The orientation session highlights the training outcomes and course content of the MB ChB programme, and focuses on the importance of this content and on outcomes, regulations and requirements related to the module, as well as on the use of the blackboard Learning Management System (LMS) (blended-learning approach).[2] The expectations of, and requirements for, registrars in training undergraduate students to become successful interns are presented during the orientation session. The HCP module has been developed specifically to enable each registrar to address their unique needs as far as ethics, practice management and patient communication are concerned. The main task of the facilitators (module leaders, module presenters, heads of department (HODs) and consultants in the specific disciplines) is to support registrars in the learning process. Various sessions are presented within the initial 24-month period of registrar training on sections of the module to provide an opportunity for all registrars to attend at a convenient time.[3] In the HCP module, the emphasis is on professional practice – where the focus is on action in clinical practice – and the purpose of mastering the required knowledge and skills is termed application, and not merely to know or to know how. Learning by doing is central to the module and therefore practical application receives considerable attention. The ability to apply knowledge that has been gained (or revisited) is of extreme importance in clinical education, training and research. Learning needs for the HCP module were identified, as registrars raised concerns about the lack of knowledge related to practice management, patient communication skills and a world-driven focus on the ethical treatment of patients.[5] The staff concerned with the development and presentation of the programme have expertise in the fields of health sciences, health professions education and higher education. Therefore, the programme is presented within the context of education for a particular health discipline. Educationists in health sciences and other subject specialists are involved co-operatively to ensure contextualisation. Guest presenters, i.e. clinicians, health sciences professionals and other professionals, facilitate the contextualisation and application of the content of the module.[5] Research mailto:bezuidj@vfs.ac.za 64 November 2013, Vol. 5, No. 2 AJHPE Research Objectives The objectives of the study were to: • Investigate whether the module on HCP addresses the needs identified by the School of Medicine, UFS, in the training of registrars regarding issues outside their specific clinical disciplines, as required by and needed as professionals. • Improve the quality of the module by identifying shortcomings and retaining aspects of importance as identified by the respondents. • Obtain the opinion of HODs on registrars regarding ethical insight, patient communication and practice management. • Determine whether the module has had an impact on professional conduct and knowledge of ethics, patient communication and practice management. Methods The study was quantitative, enhanced by qualitative methodologies. A questionnaire consisting of a 4-point rating scale (1= very weak, 2 = weak, 3 = satisfactory, 4 = very good) with open- and closed-ended questions was developed.[4] It included items related to: (i) the content of the HCP module; (ii) aspects of the module that were regarded as most beneficial; (iii) aspects of the module regarded as least beneficial; (iv) how the School of Medicine could assist with the improvement of registrar training and assessment; and (v) feedback from the HODs regarding registrars' insight into ethics, patient communication and practice management in their specific discipline.[3] A questionnaire consisting of three sections was designed to address the outcomes of the module, investigate the experiences of registrars in the module, and obtain comments from HODs on registrars’ competence in ethics, practice management and patient communication after completing the HCP module. Their findings, based on desired behaviour and feedback, were presented during academic discussions. Changes before and after completion of the module was the main focus of interest. The quantitative responses were statistically analysed using Microsoft Excel© and the qualitative statements were then categorised and summarised.[6,7] Our intent was for the quantitative data to be verified by means of the qualitative results, which aimed to identify aspects of the module that were satisfactory and those that needed to be addressed to improve quality.[8] Data were collected after every session and the questionnaire was submitted after completing the initial 24 months of training. We used the qualitative data to augment and provide additional sources of information on the module.[6] Informed consent was obtained before completion of the self-administered questionnaire. Ethical approval to conduct the study was obtained from the Ethics Committee of the Faculty of Health Sciences, UFS. Permission to involve staff and students in the study was obtained from the Head of the School of Medicine and the Vice-Rector, Teaching and Learning, UFS. Results Registrars (N=40) completed the newly introduced module GPV703 from 2009 to 2011 and 95% (n=38) completed the questionnaire. Forty questionnaires were handed out, and two respondents opted not to participate in the study. Of the questionnaires collected, 77.5% (n=31) were completed by HODs. Registrars showed ‘satisfactory to very good’ responses for the questions related to the orientation session, content and applicability of the content of the module (Table 1). Results shown in Table 1 demonstrate that the majority of registrars were positive towards the module with regard to presentations and content. Certain aspects, such as the usefulness of the module content in an e-learning format and the contents of the patient lecture on communication, need attention. Other presentations, i.e. the ethics component of the module, were well received. Registrars were less satisfied with the e-learning (blended learning) component of the module, as many of them did not have access to internet facilities on the various educational platforms. They experienced constraints related to bandwidth of the electronic blackboard LMS environment. The UFS also experienced technical difficulties related to the infrastructure, limiting accessibility to the blackboard LMS. In the section on patient communication, many registrars were unfamiliar with the skills related to communication. One of the speakers presented the subject matter inadequately and out of context and not as required by registrars in their professional context. This was reflected in the responses and rating. Qualitative data from questionnaires Responses to the open-ended questions were divided into categories according to their respective headings. Responses by registrars and HODs were allocated to themes, coded under their respective headings, and separated into responses dealing with orientation, ethics, practice management and patient communication. Qualitative responses from registrars to the question of which aspect(s) of the module were most beneficial are included, excluding repetitive phrases and statements (Table 2). Responses from registrars on the question of how the School of Medicine can assist with the improvement of registrar training are given in Table 3. Table 1. Quantitative responses from registrars regarding the orientation session, content and applicability of the Health Care Practice module (GPV703) Questions set on elements of the orientation and content of the module n Registrars' rating of the items on a Likert scale (%) 1 Very weak 2 Weak 3 Satisfactory 4 Very good 1. Orientation to aim and outcomes of module 38 0 5.3 73.9 21.1 2. Availability of module guide 37 5.4 0 62.2 32.4 3. Usefulness of module content in e-learning format 36 2.8 11.1 66.7 19.4 4. Introductory lecture on medical undergraduate education 37 0 8.1 54.1 37.8 5. Contents of ethics lecture 38 0 0 42.1 57.9 6. Contents of practice management lecture 38 0 0 55.3 44.7 7. Contents of patient lecture on communication 34 2.9 26.5 44.1 26.5 8. Relevance and applicability of module content for my own discipline 37 0 8.1 67.8 24.3 November 2013, Vol. 5, No. 2 AJHPE 65 Table 2. Qualitative responses from registrars on the question of which aspect(s) of the Health Care Practice module (GPV703) were most and least beneficial Sessions Most beneficial aspects Least beneficial aspects Orientation Undergraduate training • ‘Answered many questions.’ • ‘Better knowledge of undergraduate modules and composition of course.’ • ‘Training in the lectures (for a good foundation).’ • ‘Addresses topics that do not usually receive attention/not exposed regularly. Insight into undergraduate training which we are directly involved in.’ Non-clinical part of training • ‘Firstly, I understand the students’ role and planning.’ • ‘Better understanding of student training.’ • ‘Making aware of the non-clinical part of training.’ Outcomes of the programme • ‘It was a bit premature.’ • ‘Preparation for work when I'm done.’ • ‘Brought insight into the goals of student training.’ • ‘Questions posed made me think about these aspects of my career.’ ‘Orientation and undergraduate medical training. Introductory lecture on medical undergraduate education.’ Ethics Insight into the application of ethics in the health system • ‘Ethics lectures were of great value. Medico-legal aspects of permission update on ethics and the changes the state is envisioning for health was very good. Introduced information and broader understanding on ethics.’ • ‘Ethics lectures and Health Professions Council of South Africa (HPCSA) guidelines were well presented and the module guide to practice management.’ • ‘Consultation/presentations from non-medical professionals: improved insight into health system. Very applicable.’ • ‘Applicable clinical and practical examples were given to make ethics clearer and understandable.’ Value of ethics for registrars and undergraduate students • ‘Must be made compulsory for all registrars every year! It prepared me for the outside world.’ • ‘I enjoyed the ethics lectures. It should also be presented at undergraduate level.’ Registrars were generally satisfied. Practice management Holistic approach in management of practice and handling of patients • ‘It complements my academic learning. It encourages holistic approach in the management of patients. In future, one will be able to handle patients.’ • ‘It exposed us to an aspect of medical practice not thought about during medical training. The aspect discussed during the lecture involved practice management, ethics, communication and billing, which can be implemented both while training and in practice.’ • ‘It prepared me for private work and taught me more on government's plans with NHI.’ • Information on the new planned national health system.’ Ethics in practice management • ‘New insight in HPCSA rules regarding ethics and practice management was enlightening and to practise ethically and accordingly. Gained new insight in especially ethical matters regarding pathology practice.’ • ‘I realised that certain things I would like to include into my practice did not fit in with the ethical guidelines, like sharing a practice with someone practising alternative medicines.’ Practice rules and regulations • ‘Good information on practice rules and regulations. Better insight in respect of the decisions that need to be taken to improve the health system and all the stumbling blocks at management level.’ Legal aspects of a practice • ‘The legal and financial considerations to take into account when establishing a private medical practice, different type group practice, their advantages and disadvantages, billing arrangements, prescribed minimum benefits, advertising, malpractice insurance, utilisation management, communication skills, importance and ethics were very insightful.’ • ‘Content of training sessions not completely relevant and applicable for the discipline.’ 66 November 2013, Vol. 5, No. 2 AJHPE Research Table 2 (continued). Qualitative responses from registrars on the question of which aspect(s) of the Health Care Practice module (GPV703) were most and least beneficial Sessions Most beneficial aspects Least beneficial aspects Patient communication • ‘The communication lecture held practical benefits and examples. The communication lecture focused on what a patient expects during a consultation. Furthermore the communication lecture helped with interpersonal relationships.’ • ‘Patient communication was a poor lecture. Very little applicable.’ • ‘Session on patient communication: radio announcer had little relevance.’ • ‘Aspects such as communication – we have already had undergraduate communication as a subject.’ General comments • ‘Exposure to certain aspects, e.g. research, which you would not necessarily do in your practice. Better understanding of resources available, e.g. article research etc.’ • ‘Some of the lectures were presented in the middle of primary exams. Not a good time. Here it is aimed more at CPD marks to non-registrars as opposed to the training of registrars.’ • ‘Possibly a refresher course could be presented later for those interested, closer to the end of the course, especially practice management.’ • ‘The time of the evening, together with other clinical work and preparation. Three hours on a night is too much. Rather divide it into sessions. I don't know if it will make a difference in how doctors work.’ • ‘Never knowing when the classes are, told at last minute.’ Table 3. Improvements in registrar training programme Sessions Computer-related issues • ‘Install “Up To Date” at the hospital's computer for internal medicine ward, references and clinics. In consideration of the available resources, I think the training at this stage should not be altered too much. More focus on research. More focus on general illnesses prevalent in SA – HIV, TB, etc.’ • ‘Training on computer work and looking for information for projects.’ Ethics • ‘More information on international norms, values, ethical issues and especially practice management, in order that we can also have an idea of how other countries function – most specialists will at one stage or another be exposed to specialists from other countries.’ • ‘Maybe in-house discussions on clinically relevant ethical dilemmas.’ Time constraints • ‘Schedule classes early, please let all disciplines know sufficiently in time. We have outreach clinics that we must attend, which often conflicts with GPV703 classes. We need more time to make alternative arrangements, please.’ • ‘Sometimes there is more focus on the work that should be done than on training.’ • ‘Academic time should not be lost due to personnel shortage. Shorter but more sessions. Difficult to sacrifice 3 hours per night. Two or three sessions of 45 minutes maybe more acceptable.’ • ‘I suggest that the lectures all take place on one day, where all registrars are made available for lectures presented. The lectures can then be focused more on registrars.’ • ‘More available time for research.’ • ‘Allocating time for research required to complete MMed degrees.’ E-learning • ‘They can put interesting articles on the e-learning website on a regular basis.’ Academic platform, training and government issues • ‘Continual pressure on the government for a bigger budget to improve working conditions regarding equipment, consumables, etc.’ • ‘Apply determined academic time, in spite of personnel shortage. More tender time. Maybe more information on practice management.’ • ‘In my opinion, I believe the improvement can come with addition of more aspects to GPV703, for example, how to build good working interdepartmental relations.’ • ‘Optimise current sessions. More practical guidance in research. Current sessions already very good, but would like to know which part done at e.g. biostatistics, and when they should be consulted.’ • ‘Think we have more than ample opportunity in our department to improve learning. (Self-study and own motivation is important, but it is the student's own responsibility.)’ General • ‘Create opportunity to attend lectures/courses dealing with relevant topics. Quarterly registrar meetings where concerns and problems can be raised.’ • ‘Lectures and/or information pieces in respect of the business aspects and financial implications of establishing and running a practice (part-time and full-time). More courses like GPV703.’ Editorial November 2013, Vol. 5, No. 2 AJHPE 67 Research Assessment by HODs on registrars' compre- hension, insight and application of ethics, patient communication and practical management in their specific disciplines are given in Table 4. Discussion Knowledge of ethics, patient communication and practice management is essential for the practice of clinical medicine. These skills are needed by all practitioners, especially those in private practice (the majority of doctors in South Africa). The study results showed that the module on HCP addresses these aspects during the training of registrars. The majority of registrars were satisfied with the presentations and content of the modules. This was not the case for the presentation on communication skills. More information is needed to better understand the problems associated with this topic in which the content was not presented in an appropriate professional context. E-learning challenges also need to be addressed. Because e-learning is often a problem in the developing world, its use needs to be carefully reconsidered. Ethics is frequently discussed in interviews epitomising its role in clinical practice. Registrars have made a huge contribution to improve the quality of the HCP module. They contributed significantly to assist the School of Medicine with regard to presentation times, multiple presentations, quality of presenters and aspects related to module content. Other aspects directly related to the training of registrars were referred to HODs. Registrar feedback provided a platform to identify shortcomings in their training and was shared with HODs in a feedback session. Improvements suggested by registrars are fairly simple to address (Table 3). The results showed that HODs observed a general improvement in registrars' insight, comprehension and application related to ethics, patient communication and practice management in this module, i.e. they observed progress and scored the registrars, but were reluctant to comment on or motivate their answers. This progress was based on their previous (superficial) observations and evaluations of registrars. Of the 31 questionnaires completed by HODs, 17 registrars were given an above-average and 14 an average score on the selected criteria. No registrars received a below-average score. HODs indicated that they were under pressure as a result of staff shortages and service delivery needs and requested that they are not asked to participate in the completion of the questionnaire in future, i.e. their inputs would not be sustainable. The opinions of HODs on registrars' insight into ethics, patient communication and practice management obtained from the present study will be used to adapt the HCP module and select appropriate presenters for the future. Conclusion The module on HCP (GPV703), as implemented by the UFS, is successful in addressing key aspects often neglected because of the strong clinical focus of a medical programme. Acknowledgements. We gratefully acknowledge assistance received from participating students and medical school staff involved in data collation. We appreciate the input of Prof. Vanessa Burch (UCT) related to editing and insight in writing this article. References 1. University of the Free State. Selection information for MBChB students. Faculty of Health Sciences. School of Medicine. Bloemfontein: University of the Free State, 2009:1-10. 2. University of the Free State. Yearbook of the Faculty of Health Sciences. School of Medicine. Post-Graduate/Advanced Degrees and Diplomas. Bloemfontein: University of the Free State, 2011. 3. Van der Merwe W. The Worcester CBE Model. Faculty of Medicine. Stellenbosch: University of Stellenbosch, 2011. 4. Hugo J. The University of Pretoria CBE Model. Pretoria: University of Pretoria, 2012. 5. Nel MM, van Zyl GJ, Bezuidenhout J. Module in Health Care Practice (GPV 703) for MMed Programme: Bloemfontein: University of the Free State, 2007. 6. Johnson RB, Onwuegbuzie AJ. Mixed methods research: A research paradigm whose time has come. Educational Researcher 2004;33:14-26. [http://dx.doi.org/10.3102/0013189X033007014] 7. Creswell JW. Research Design: Qualitative and Quantitative Approaches. California: Sage Publications, 1994. 8. Creswell JW. Educational Research. Planning, Conducting, and Evaluating Quantitative and Qualitative Research. 3rd ed. New Jersey: Pearson Prentice Hall, 2008. Table 4. Comments from heads of department interviewed Theme Comments Ethics • ‘Her feeling is that ethical handling of a patient is part of who you are and comes naturally. The session on ethics made her aware of her relationship with patients but did not mention her colleagues or society.’ • ‘Ethics has been neglected in the training of registrars. The registrar’s patient communication skills really progress after the attendance of the GPV703 module. I think the module “ripens” registrars for the real life situations and environment they would face once they completed their studies.’ • ‘Own experience and feedback received from fellow colleagues indicate a good comprehension and feeling of ethical aspects in the treatment of patients. She has insight with regard to ethical relations with patients, colleagues and industry.’ • ‘Own experience and feedback from colleagues reflect good insight on ethical issues encountered in patient care and good communication skills.’ Patient communication • ‘She gave good feedback on guidance on communication skills. The registrar has excellent bedside manners and is thorough in explaining to patients.’ • ‘Have good communication skills with parents and children as patients. Organisational skills during service delivery situations is satisfactory.’ • ‘She experienced the patient communication and speaker as not applicable to her need and level of communication with patients. After her explanation I understood her opinion.’ • ‘The student did not experience the lecture on patient communication as relevant and applicable in her context of work.’ Practice management • ‘The session on practice management is still far away in her mind but gave her good insight on what awaits her. She has an opinion of her future career but is unsure where she wants to practice.’ • ‘She has good insight in the ethical relationship between doctor and patient, but also with her colleagues and the rest of the industry. Practice management is far removed and futuristic. We informed her that she must start to position herself for the future and its realities in having her own practice in a healthcare system.’ General • ‘Comments to the module development team from HODs.’ • ‘One can feel proud on what has been achieved with the module.’ http://dx.doi.org/10.3102/0013189X033007014]